Comparison of clinical risk scores for triaging high-risk chest pain patients at the emergency department.

BACKGROUND: Many of the clinical risk scores routinely used for chest pain assessment have not been validated in patients at high risk for acute coronary syndrome (ACS). We performed an independent comparison of HEART, TIMI, GRACE, FRISC, and PURSUIT scores for identifying chest pain due to ACS and for predicting 30-day death or re-infarction in patients arriving through Emergency Medical Services (EMS).

METHODS AND RESULTS: We enrolled consecutive EMS patients evaluated for chest pain at three emergency departments. A reviewer blinded to outcome data retrospectively reviewed patient charts to compute each risk score. The primary outcome was ACS diagnosed during the primary admission, and the secondary outcome was death or re-infarction within 30-days of initial presentation. Our sample included 750 patients (aged 59 ± 17 years, 42% female), of whom 115 (15.3%) had ACS and 33 (4.4%) had 30-day death or re-infarction. The c-statistics of HEART, TIMI, GRACE, FRISC, and PURSUIT for identifying ACS were 0.87, 0.86, 0.73, 0.84, and 0.79, respectively, and for predicting 30-day death or re-infarction were 0.70, 0.73, 0.72, 0.72, and 0.62, respectively. Sensitivity/negative predictive value of HEART ≥ 4 and TIMI ≥ 3 for ACS detection were 0.94/0.98 and 0.87/0.97, respectively.

CONCLUSIONS: In chest pain patients admitted through EMS, HEART and TIMI outperform other scores for identifying chest pain due to ACS. Although both have similar negative predictive value, HEART has better sensitivity and lower rate of false negative results, thus it can be used preferentially over TIMI in the initial triage of this population.